Prescription Coverage (Formulary)

PrimaryHealth has many prescription medications that are covered and these medications are provided without copay to the member. While prescription medications treating covered conditions are a benefit under the Oregon Health Plan (OHP), not all prescription medications are covered under the PrimaryHealth medication list (formulary). Please contact the PrimaryHealth office if you have any questions about prescription medications or if you need help with a prior authorization.

PrimaryHealth Medication List (the “Formulary”)

PrimaryHealth has a list of medications (called the “formulary”) that are covered by PrimaryHealth. This formulary is effective on and after January 1, 2017. Pharmacists and doctors help PrimaryHealth decide which medications should be in the formulary. To get up-to-date information about medications covered by PrimaryHealth, Call us at one of the following numbers between 8am-5pm Monday-Friday:

Member Services 541-471-4208 in the Grants Pass Area

Toll-Free 1-800-471-0304

TTY 1-800-735-2900

Listed medications are used because they are effective in treating the condition being prescribed for and are cost effective. PrimaryHealth may add or remove medications or change coverage requirements on medications when appropriate. When we remove a medication from the list or add restriction to a medication that you are taking, we will tell you in advance. These items are not covered:

Medications not listed in the formulary

Medications removed from the formulary in updates

Medications used to treat conditions that are not covered by the Oregon Health Plan, such as fibromyalgia, acne, and chronic back pain

Medications used for cosmetic purposes

Medications used for not medically accepted indications, or “off-label”

Investigational medications and medications used in an investigational manner.

If a prescriber orders a medication for a PrimaryHealth member that is not on the PrimaryHealth list, we will ask the prescriber to choose a medication from the formulary. If the prescriber thinks there is a reason that a listed medication is not safe or effective for the member, PrimaryHealth will work with the prescriber for possible solutions.

Over-The-Counter Medications

PrimaryHealth pays for over-the-counter medications that are on our list, such as aspirin, if an approved provider has written you a prescription for the medication.

Mental Health Medications

PrimaryHealth benefits do not cover mental health medications. However, OHP benefits do cover mental health medications, which are paid for by the state through the Division of Medical Assistance Programs. There may be a small copay for mental health medications. For help with getting a prescription for mental health medications, call DMAP at 1-800-527- 5772 or TTY 800-375-2863.

Pharmacy Network and Allowed Quantities

You may use any pharmacy of your choice that will accept your PrimaryHealth Medical ID card. PrimaryHealth has arrangements with most of the pharmacies in the Josephine County area. If you are out of the area and need a prescription filled, go to the nearest “chain” pharmacy, for example: Bi-Mart, Rite-Aid, Safeway or Wal-Mart. Call PrimaryHealth if you have any questions about which pharmacy you may use. The pharmacist may need special approval by PrimaryHealth to fill some medications.

You may receive up to a 30-day supply of medications you take regularly. The earliest day you can get a refill is 26 days after you last filled your prescription. This is the normal amount for such a prescription. Prescriptions are filled with generic medications whenever possible.

Prior Authorization

PrimaryHealth decisions for prior approval and medication list exceptions are based only on appropriate care and coverage. PrimaryHealth staff is not rewarded for denying requests and do not use financial incentives that reward denying services. PrimaryHealth may approve a 30-day transition supply of an unlisted medication for a chronic medical condition for members who were taking the drug before they became a PrimaryHealth member or after discharge from a hospital or nursing facility. You or your doctor can contact PrimaryHealth to ask for help with coverage of a transition medication.

To obtain a prior authorization, your pharmacy needs to fax a request to PrimaryHealth at (541) 471-4208. PrimaryHealth contacts the prescriber, if necessary, and collects all information needed to process the prior authorization. We will notify the pharmacy and prescriber of our decision. If the medication is denied, we also send a Notice of Action letter to the member, which explains the denial and what to do to appeal if they do not agree.

Pharmacist Instructions

Please Fax all PBM Rejections/”Denials”/ Prior Authorizations to PRIMARYHEALTH at (541)956-5460. PRIMARYHEALTH will coordinate PA’s with the provider.

For Mental Health Medications, bill State of Oregon/Fee-For-Service Medicaid. PRIMARYHEALTH covers a maximum 30 day supply. Rx must be 85% used prior to refill. PRIMARYHEALTH will respond to PA requests with a faxed decision. All denials are faxed to PCP, Pharmacy and Prescriber.

All meds > $500 require PA.

To Access After Hours Assistance with Urgent Pharmacy Requests Contact the MedImpact Help Desk at 1-800-788-2949

Dual Coverage with Medicare

This information is for any member who has Medicare and Medicaid (OHP) coverage. This drug benefit is Part D of Medicare coverage. Medicare requires copay for Part D medication coverage. Most of the plans that provide a drug benefit will charge a copay from $1 to $6.50. PrimaryHealth will continue to pay for all other covered health services. PrimaryHealth covers over-the-counter, and some benzodiazepine/barbiturate drugs for Medicare duals.

Other Drug Coverage Restrictions

Some medications on the list have additional coverage requirements or limits that may include:

The use of generic drugs, when available

Prior approval by PrimaryHealth (see below) • Step therapy

Age restrictions

Quantity limit

Formulary Key

More specific information about Medication Prescribing Limitations is included in this document immediately following the drug list.